Relationship between nurses’ knowledge of COVID-19, professional quality of life, and practice during the COVID-19 pandemic: A descriptive correlational study

The purpose of this study was to examine knowledge, professional quality of life, and practices among nurses during the coronavirus disease 2019 (COVID-19) pandemic and explore factors associated with nurses’ practice. A total of 167 nurses were recruited from 4 general hospitals for this cross-sectional study, which was conducted from June to July 2021. Using SPSS/WIN 22, the collected data were analyzed using descriptive statistics, t-tests, analysis of variance, Pearson’s correlation coefficients, and hierarchical multiple regression analysis. The mean age of the participants was 31.43, and the sample comprised 144 women (86.2%) and 23 men (13.8%). The results indicated that practice was negatively correlated with burnout (r = -.18, p = .017). The regression model explained 24.1% of the variance. For general characteristics in Model 1, education on COVID-19 management (β = .18, p = .014) was the factor most associated with nurses’ practice. In Model 2, with professional quality of life added, burnout (β = -.21, p = .003) was the only influential factor. These results highlight the need to establish an effective prevention system for infectious diseases such as COVID-19, including education programs pertinent to the prevention and management of infection that improve the modifiable predictors of nurses’ practice—education and burnout.


Introduction
After the reporting of the first case in Wuhan, China in December 2019 [1], the coronavirus disease 2019 (COVID-19), a communicable infectious disease, quickly escalated to a pandemic [2]. As of May 22, 2022, more than 502.2 million confirmed cases and 6 million deaths were reported, and the global excess mortality estimate for 2020-2021 was 14.9 million [3]. The pandemic has strained healthcare systems and inflicted socioeconomic damage worldwide [4].
Furthermore, as of August 5, 2021, approximately 522,219 and 1,677 healthcare professionals had contracted and died from COVID-19, respectively, in the United States [5], with approximately 5.5% of the nursing population having been infected [6]. However, these figures do not accurately reflect the actual number of healthcare personnel affected by COVID-19, as some patients only develop mild symptoms or are asymptomatic [6]. The key to preventing the spread of infection within hospitals includes the early discovery of suspected cases through close monitoring and strict adherence to isolation guidelines [7]. Studies have reported that healthcare professionals display a moderate level of knowledge and attitudes toward infectious diseases [8], suggesting that only a small fraction strictly adhere to the correct precautions [9]. In China, infection among healthcare professionals was reported to be common among frontline healthcare staff in Wuhan but not in other regions [10,11].
Negligence and lack of knowledge were pinpointed as responsible for the quick spread of infection in the early days of the pandemic [10,11], showing that a lack of knowledge among healthcare professionals can contribute to disease infection and spread. COVID-19 is highly transmissible and causes asymptomatic cases in communities [12,13]. Furthermore, an effective response to infectious diseases is hindered by a lack of knowledge about risks and response measures [14], highlighting the importance of nurses' knowledge regarding COVID-19.
Professional quality of life (ProQOL) is defined as individual negative and positive emotions in relation to helping others who are experiencing pain or trauma. ProQOL has two components: compassion satisfaction (CS) and compassion fatigue (CF) [15]. CS is a pleasurable feeling derived from having the ability to help others [15]. CF has two components: 1) burnout associated with exhaustion, frustration, anger, and depression; and 2) secondary traumatic stress (STS), a negative emotion resulting from fear and task-related trauma [15]. Burnout refers to the development of empathy fatigue that can occur in professional caregivers while caring for various individuals [16]. STS occurs when the stress experienced in the process of maintaining close contact with the patient to help the patient gradually accumulates without being resolved [17]. Nurses' ProQOL is an essential factor that contributes to patient care [18], and nurses' perceived meaning of life, purpose, and values have a major impact on their own quality of life [19]. Nursing practice can be a satisfying experience based on compassion; however, compassion can also negatively affect nurses' physical and mental health and practices [20]. Nursing professional value shows a positive correlation with pleasant feelings derived from providing care, a dimension of ProQOL known as CS, which improves clinical care quality and nurse job satisfaction [21]. Nursing professional value guides clinical practice professionally and ethically and forms nurse identity [22]. A decrease in satisfaction with compassion can lead to compassion-related avoidance behavior, which can reduce nurses' compassion toward patients and, ultimately, their competence and quality of clinical practice. [23,24]. In Zakeri et al.'s [25] study, there was a significant correlation between clinical competency, CS, STS, and burnout, and regression analysis showed that people with high CS had strong resistance to STS and burnout and high clinical competency. In a study by Hooper et al. [26], interventions that can increase CS and lower burnout and STS are recommended to help nurses provide quality patient safety and maintain a caring attitude in practice. Burnout can cause physical and mental problems in nurses, such as insomnia, headaches, poor concentration, long-term fatigue, and irritation. This can result in poor quality of care and patient satisfaction and increased medical errors, malpractice, morbidity, and mortality [27].
According to a study comparing 2020 and 2021 data of advanced practice providers caring for patients with COVID-19, in 2021, 97.67% of respondents had been vaccinated. Despite a decrease in risk perception, stress levels remained high (2020 vs 2021 = 75.6% vs 90.7%; p = 0.09) as thoughts of resignation increased (2020 vs 2021 = 0.0% vs 11.6%; p = 0.01) [28]. Additionally, in 2021, 57% of participants reported moderate or high levels of traumatic stress and 75% reported moderate or high levels of burnout, while only 7% of participants reported high levels of compassion satisfaction [28].
Nurses are healthcare professionals who provide direct patient care and play a crucial role in the prevention and management of infections [29]. Job-related stress factors, such as CF and burnout, adversely affect their clinical decision-making [30], quality of patient care [30], clinical competency [30], and practice [31]. Although several studies have evaluated nurses' knowledge, attitudes [32], practice [33][34][35], and perceptions and level of confidence [35] in the context of COVID-19, research has not comprehensively evaluated various aspects of knowledge, ProQOL, and practice. Therefore, this study examined nurses' knowledge, ProQOL, and practice during the COVID-19 pandemic and explored factors that influence nurses' practice, ultimately presenting foundational data for developing measures to effectively prevent the spread of infectious diseases in the future.

Objectives and hypotheses
The specific objectives were as follows: 1) to examine nurses' characteristics, knowledge, Pro-QOL, and practice during COVID-19; 2) to analyze the correlations between knowledge, Pro-QOL, and practice during COVID-19; and 3) to identify the factors associated with nurses' practice during COVID-19. This study examines how the variables (nurses' characteristics, knowledge, and ProQOL), in each category, were associated with nurses' clinical performance, as presented in Fig 1. Thus, the following hypotheses were established (Fig 1): 1. Nurses' knowledge level has a positive association with practice.
2. Nurses' characteristics are associated with practice.
3. Nurses' ProQOL is associated with practice. Specifically, nurses with higher levels of CS and lower burnout and STS engage in better clinical performance.

Study design/sampling
This was a cross-sectional, descriptive, and correlational study that analyzed the factors associated with nurses' practice by examining the relationship between their knowledge levels, Pro-QOL, and practice during the COVID-19 pandemic. Access to the study participants was obtained after acquiring consent from the nursing director of each medical institution. The inclusion criteria for participating in this study were being registered as a qualified nurse, working in the Republic of Korea, and being willing to participate in the study. Employees outside these parameters, such as nursing students and medical assistants, were excluded. To avoid researcher bias, a questionnaire was distributed to all participants who volunteered and met the inclusion criteria, through the relevant clinical nurse manager, who received a briefing on the study from the appropriate nursing supervisor before distribution of the questionnaire. No incentives were provided, no tips on completing the questionnaire were provided, and participation was anonymous.

Sample/Participants
The sample size was determined using the G*Power 3.1 program [36]. For a regression analysis with a significance level (α) of .05, power of .95, and eight predictor variables (three general characteristics, knowledge, ProQOL [CS, burnout, STS], and practice), the minimum required sample size was calculated to be 160. Considering a 10% withdrawal rate, data were collected from 175 participants. The inclusion criteria were being over 18 years old, working in patient care at the time of the survey, and completing the questionnaire. After excluding 8 questionnaires with careless and missing responses, 167 were included in the final analysis.

Data collection
After explaining the purpose and contents of this study to the head of the nursing department and the head of the nursing education team at each hospital, approval was obtained. A researcher was assigned to each hospital and distributed the questionnaire, explained the purpose of the questionnaire, obtained consent to participate, and personally collected the completed questionnaire.
Data were collected from staff nurses, charge nurses, and nurse managers who worked in tertiary, secondary, and national forensic psychiatry hospitals in four cities of the Republic of Korea. Data collection was conducted using a self-report questionnaire during the COVID-19 pandemic, between June and July 2021. The questionnaire that was used to obtain data regarding the participants' knowledge and practices is presented as S1 Appendix.

Knowledge and practice
The Knowledge and Practice Toward COVID-19 Scale [37] was used. The knowledge subscale comprises 10 items (causative agent, incubation period, mode of transmission, main symptoms, confirmatory diagnosis, high-risk population for severe outcomes, preventive measures, current management options, possible complications, and mortality rate), each of which is rated from 0 to 10. A score of � 7 indicates adequate knowledge [37].
The practice subscale comprises five items, each of which is rated on a five-point Likert scale. Scores range from 5 to 25, with higher scores indicating better practice. A score of � 18 indicates an appropriate level of practice, and a score of � 17 indicates an inappropriate level of practice [37]. In this study, the Cronbach's α for the knowledge and practice subscales were .74 and .72, respectively. Cronbach's α was .74 for the overall scale at the time of development.

Data analysis
The collected data were analyzed using SPSS 22.0 (IBM Corp., Armonk, NY, USA). The Shapiro-Wilk test was performed to assess the normality of the distribution of continuous variables. Participants' general characteristics, knowledge, ProQOL, and practice were presented as either frequency and percentage or mean and standard deviation. Differences in practice according to general characteristics were analyzed by performing a t-test and analysis of variance. Correlations between knowledge, ProQOL, and practice were analyzed by calculating Pearson's correlation coefficients. Further, the associations between practice and general characteristics, knowledge, and ProQOL were analyzed by performing hierarchical regression. Statistical significance was set at p < .05.

Ethical considerations
This study was conducted in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans. After obtaining approval from the institutional review board of Chungnam National University Sejong Hospital (CNUSH 2021-05-017-005), the participants were informed about the purpose and content of the study, anonymity and confidentiality, use of data only for research purposes, voluntary participation, and freedom to withdraw without repercussions at any time. Data were collected from nurses who voluntarily provided written consent.

Descriptive statistics
Characteristics of the participants. Previous studies [39][40][41][42][43] have shown that infection control education is a significant factor in explaining practice; this study included several variables (e.g. effect of COVID-19 education, understanding of COVID-19) to further refine the factors affecting practice. Most participants (86.2%) were women; the mean age was 31.43 years, with 51.5% aged < 30 years. Further, most participants were single (72.5%) and had a bachelor's degree (82%). Many participants lived alone (47.9%), and 49.7% had no children. Approximately 70.7% worked at a tertiary hospital, the mean length of employment was 1.90 years, and 48.5% had worked for less than 5 years. The most common monthly income was 2-3 million KRW (65.9%), and the most common work unit was intensive care (33.5%). Moreover, most participants (88.6%) were staff nurses. The vast majority (95.2%) worked rotating shifts, and 56.9% worked 5-6 night shifts per month. Approximately 33.5% were satisfied with their jobs, and 56.3% had provided care for patients with COVID-19. A total of 85.6% had prior COVID-19 management training, and 91.6% were vaccinated against COVID-19. Approximately 85.6% of the participants feared spreading the infection to their families, and 27.6% felt supported by their superiors. Of the participants, 38.3% claimed to be confident in the COVID-19 response, and 53.3% had reduced anxiety about infection after receiving COVID-19 vaccination ( Table 1).
Level of knowledge, ProQOL, and practice related to COVID-19. The mean knowledge score was 6.95 ± 1.54 out of 10 (Range: 2-10) ( Table 2). Notably, a high percentage of the respondents exhibited good knowledge of COVID-19, recording 94.6% and 92.8% correct answers for the Preventive measures and Incubation period items, respectively. The item with a correct answer rate of less than 50% was Mode of transmission ( Table 3). The mean practice score was 21.20 ± 3.69, and 82% demonstrated an appropriate level of practice. The items with the highest and lowest correct answer proportion were preventive measures (94.6%) and causative agent (62.3%), respectively ( Table 2).
The mean CS score was 27.65 ± 7.86, and 115 nurses (68.9%) had a moderate level of CS. The mean burnout score was 29.32 ± 5.94, and 144 nurses (86.2%) experienced a moderate level of burnout. The mean STS score was 23.03 ± 6.64, and 76 nurses (45.5%) experienced a moderate level of STS ( Table 2).
The mean practice score was 21.20 ± 3.69 out of 25 (Table 2). By domain, the score was the lowest for "Implementation of five moments of hand hygiene with seven steps" (3.95 ± 1.01) and the highest for "Careful doffing of personal protective equipment" (4.49 ± 1.00; Table 3).

Differences in practice according to participants' characteristics
Infection control unit nurses showed significantly better performance of COVID-19 practices than other ward nurses (F = 13.94, p < .001). The practice scores of nurses with care experience for confirmed cases of COVID-19 (t = 5.67, p < .001), nurses with COVID-19 management education (t = 3.17, p = .004), nurses who perceived the education to be very effective (F = 4.55, p = .002), and nurses who had a very good understanding of COVID-19 (F = 10.04, p < .001) was also found to be significantly high. The practice scores of nurses without fear of COVID-19 infection to the family (t = -2.07, p = .040), nurses who perceived adequate support from their supervisors (F = 2.96, p = .045), nurses with strong confidence for coping with COVID-19 (F = 5.96, p = .003), and nurses with dispatch experience (t = 4.81, p < .001) were significant (Table 4).

Predictors of COVID-19-related practice
The Durbin-Watson statistic was 2.003, and the variance inflation factor was 12.259, 10.382, and 9.772 for work units, effects of COVID-19 education, and support from superiors, respectively. Therefore, these three variables were removed from the regression analysis because they showed multicollinearity. Then, the Durbin-Watson statistic was 1.814, and the correlation coefficients were below .67. There was no autocorrelation of the error term, and the tolerance ranged from 0.453 to 0.992, with the variance inflation factor ranging from 1.948 to 5.434, confirming the absence of multicollinearity. Furthermore, there were no sociodemographic factors that statistically significantly varied in relation to practice.
To identify the variables associated with practice, the general characteristics shown to be differently correlated with the practice dimensions were input as independent variables. Model 1 included nurses' general factors and Model 2 included variables that were significantly different among ProQOL factors; these were input as explanatory variables. The general characteristics that statistically significantly differed in relation to practice-prior COVID-19 care experience, understanding of COVID-19, fear of spreading COVID-19 infection to family, confidence in COVID-19 response, and prior floating experience-were entered as independent variables. Model 1's regression equation was statistically significant (F = 6.27, p < .001) and explained 24.1% of the variance in COVID-19 practice. Prior COVID-19 education was identified as a predictor (t = 2.49, p = .014). In Model 2, burnout, which differed statistically significantly according to practice, was also entered. Model 2's regression  equation was also statistically significant (F = 6.79, p < .001), and the percentage of explained variance increased by 3.8% to 27.7%. Burnout was identified as a statistically significant predictor of clinical practice (Table 6).

Discussion
In this study, 65.9% of the participants displayed an adequate level of knowledge. This is similar to previous findings that non-physician healthcare professionals, including nurses,  [37,43]. Further, among care behaviors, "knowledge and skills" received the lowest score [44], contradicting a report that this group demonstrated a high level of COVID-19-related knowledge, including with regard to disease symptoms [32,44]. The diversity of study populations, varying content of scales measuring knowledge by domain, and different evaluation criteria probably influenced the results. However, given that the study population primarily comprised nurses working in hospitals designated to manage patients with COVID-19, who lacked knowledge about the route of COVID-19 transmission, continued COVID-19 education with up-to-date information and evidence-based knowledge that addresses the characteristics of the disease is essential. Similar to our study, another study [45] showed that healthcare providers did not have sufficient knowledge of the signs, transmission, prevention, and treatment of COVID-19. In El-Monshed et al.'s study [46] the proportion of correct answers was higher than 85% during the main symptom and incubation period, similar to the results of this study.
The current participants showed a moderate level of CS, burnout, and STS. Specifically, 73.1% demonstrated a moderate or high level of CS, a positive construct, with the percentage of participants with moderate or low levels of burnout and STS, which are negative constructs, at 97% and 100%, respectively. Similar results were reported by a study of emergency department nurses before the COVID-19 pandemic [47], a study of US nurses [48], a study of intensive care unit and isolation ward nurses after the outbreak of COVID-19 [49], and a study of Wuhan nurses [50]. This is different from a study with Chinese nurses, in which CS was moderate, and burnout and STS were low [51]. The study results may differ depending on the situation in each country, hospital, or work environment. It has been reported that providing a supportive work environment [52], reasonable shift schedules for limiting nurses' work hours [53], reducing burnout among nurses, and providing psychological counseling services may affect STS [50]. The findings highlight the need for systems or policies that boost CS and reduce STS and burnout to enhance the efficiency of nursing work and quality of care, regardless of COVID-19. Approximately 82% of the participants displayed appropriate practice, similar to previous findings that 78.9% of healthcare workers demonstrated appropriate practice [35] and that nurses "frequently" or "always" adhered to the isolation guidelines (score 3.34/4) during the MERS epidemic [29,43]. Although handwashing is an effective means to prevent the spread of infection [45,54], the practice score for this domain was the lowest (3.95) in our study, thus calling for continued education and monitoring.
Knowledge and practice were not significantly correlated in this study, similar to previous findings [46,47,55,56]. However, this contrasts with the findings of Zhang et al. [11]. Although this study was conducted during the delta variant wave, 34.1% of the participants demonstrated an inappropriate level of knowledge, and the mean knowledge score was also below the cutoff set by the instrument developer. Increasing knowledge and awareness of infection can facilitate better practice, such as the correct use of personal protective equipment, which can help halt the spread of infection [48,57]. In this study, it was observed that prior COVID-19 response education and training positively contributed to practice despite a low knowledge score. Therefore, COVID-19 education should include basic content, such as mode of transmission and high-risk populations for severe outcomes.
Job-related factors that significantly influenced practice were working in the infectious disease ward, prior COVID-19 care, prior education, effects of education, understanding of COVID-19, fear of spreading COVID-19 to family, support from superiors, confidence in COVID-19 response, and prior floating experience. These results are similar to those of previous studies that identified working in an infectious disease ward, prior COVID-19 or MERS care experience, prior education, and understanding of education as predictors of nurses' adherence to isolation guidelines during the MERS epidemic [37] and COVID-19 pandemic [47,56]. It seems that nurses working in infection isolation wards follow the guidelines more strictly to protect themselves and provide better patient care [49,58]. COVID-19 education and prior COVID-19 care experience also seem to boost nurses' understanding of the disease and help follow isolation guidelines more proficiently [50,59].
Regardless of exposure status, healthcare professionals who provided care for patients admitted via an ambulance or older adults with multiple comorbidities during the COVID-19 pandemic showed greater fear of infecting their families [51,52,60]. Further, during the 2009 H1N1 pandemic, fear that their families would die from the virus was associated with lower willingness to work [53,61]. Therefore, the level of practice in our study population may have been influenced by the participants' high level of fear of spreading the infection to their families, as the sample comprised many nurses working in units that care for vulnerable populations who can readily experience negative outcomes (complications) from COVID-19 infection, such as patients in the emergency department, intensive care unit, and infectious disease wards. Similar to our findings, previous studies reported that support from superiors [54,62] and confidence in response measures [11] significantly influenced nursing practice during an infectious disease outbreak. Support from superiors, such as sharing of information, provision of education, and monitoring of nursing practice, may motivate nurses to adhere to safety protocols and commit to their jobs and boost their confidence in their response capability during the pandemic, positively influencing their practice.
However, studies examining the association between floating and practice are lacking. During the COVID-19 pandemic, nurses who were transferred to a different unit had a high fear of infection and showed a significantly greater prevalence of depression and anxiety [55,63]. Such negative emotions may adversely impact their work stress, job satisfaction, patients and their families, and organization by decreasing their work efficiency [56,64]. Conversely, a previous study [57,65] reported that depression and anxiety are not significantly associated with nurses' practices, such as handwashing and use of personal protective equipment, calling for further research on the relationship between floating and practice.
Hierarchical regression was performed to identify the predictors of nurses' practice. Model 1, which comprised job-related factors, explained 24.1% of the variance in practice, and prior COVID-19 education was the key predictor. Ramirez-Baena et al. [66] reported that training and education about the etiology of a novel infectious disease, infection prevention, and infection control might enhance nurses' knowledge and skills and that prior COVID-19 education seems to have had a positive influence on nurses' practice in this study. These results are contrary to those of a study on healthcare professionals [67] However, this could be attributed to the difference in the proportion of participants with prior education in the said (68.9%) and current study (85.6%).
Model 2 explained 27.7% of the variance, and burnout was identified as another significant predictor of practice, in addition to COVID-19 education. Previous studies have reported that low burnout is associated with better hand hygiene practices [68]. Healthcare professionals providing HIV care are more likely to engage in unprofessional behaviors and provide suboptimal care (shouting at patients, not performing diagnostic tests owing to a desire to finish quickly) when they are burned out [69]. Further research is needed on burnout and practice to gain a more accurate understanding of the effects of burnout on practice during an epidemic of an unknown infectious disease, such as COVID-19.

Limitations
This study has some limitations. First, the study population, which included selected hospitals, was not representative of the entire nursing population, which diminishes the generalizability of the findings. Second, this was an observational, cross-sectional study. Therefore, causality could not be firmly established, and changes over time could not be observed. Third, the identified predictors explained < 30% of the total variance in each model. Additional studies are needed to measure other nursing work environment factors (appropriateness of staffing and workload, support from superiors, and patient acuity) and analyze their associations with practice.
Despite these limitations, this study comprehensively examined nurses' knowledge, Pro-QOL, and practice. Unlike previous studies that only addressed nurses' knowledge, attitudes, and practice, the findings of this study could help establish strategies to prevent the spread of infectious diseases.

Conclusions
In this study, the aim was to examine the knowledge of COVID-19 isolation guidelines, Pro-QOL, and practice among nurses and identify the predictors of practice. The participants demonstrated an inadequate level of COVID-19-related knowledge, moderate ProQOL, and an appropriate level of practice. Prior COVID-19 education and burnout were significant predictors of practice. These results highlight the need to establish an effective prevention system for infectious diseases such as COVID-19 by implementing policies and other measures, including education programs pertinent to the prevention and management of infection that improve the modifiable predictors of nurses' practice-education and burnout.

Implications for practice
This study revealed an unprecedented result, in that while clinical nurses' level of knowledge about COVID-19 did not affect their practice during the pandemic, which was a time of continued uncertainty, a high level of knowledge was positively associated with practice. Therefore, educational programs focusing on knowledge that can enhance the practical aspects of nursing are needed, rather than theoretical knowledge.
Exhaustion was negatively associated with practice. In an infectious disease epidemic, nurses' practice can have a negative impact on patient safety and care quality. Therefore, support systems, including psychological support, which can reduce nurses' burnout, are essential for nursing managers and nursing leaders, and should be considered in governmental policies.
Although the study collected data after vaccination against COVID-19 and relaxation of precautions, most participants experienced a moderate level of burnout, and 45.5% of participants experienced a moderate level of STS. Burnout was a significant factor affecting nurses' performance. Regardless of the COVID-19 pandemic, counseling and education programs and feedback that can reduce nurse burnout and STS and improve practical performance are essential from a policy point of view.
Based on the present results, education on COVID-19 management is positively associated with practice, suggesting that education is an important strategy by which to improve practice. Considering that the proportion of correct answers was low for basic knowledge, such as causes of COVID-19, mortality, and management, systematic education including basic knowledge and testing of the effectiveness of education are also necessary.
Leaders and managers of healthcare institutions must strive to identify the causes of burnout among nurses, and professionals must develop strategies to reduce burnout by increasing CS and reducing STS, so that practice can be improved.